This invention is related to the medical office automation industry and more particularly to the field of forming medical records in the medical industry.
Over the years, various office automation equipment has been developed for providing offices with automatic systems for dictation, transcription, word processing, financial analysis, and other office functions which could be automated. This office automation equipment generally applied to all types of offices including sales, financial, legal, insurance, research, medical and various service or other business offices. Each type of office or general field of the office, however, often has their own constraints and problems for office automation equipment. The medical field, for example, has attempted to automate the diagnosis of a patient""s illness based upon a patient""s symptoms and then often recommended a corresponding patient treatment. Examples of such systems can be seen in U.S. Pat. No. 4,733,354 by Potter et al. titled xe2x80x9cMethod And Apparatus For Automated Medical Diagnosis Using Decision Tree Analysis,xe2x80x9d U.S. Pat. No. 4,839,822 by Dormond et al. titled xe2x80x9cComputer System And Method For Suggesting Treatments For Physical Trauma,xe2x80x9d U.S. Pat. Nos. 4,872,122 and 5,005,143 by Atlschuler et al. and each titled xe2x80x9cInteractive Statistical System And Method For Predicting Expert Decisions,xe2x80x9d and U.S. Pat. No. 5,692,220 by Diamond et al. xe2x80x9cDecision Support System And Method For Diagnosis Consultation In Laboratory Hematopathology.xe2x80x9d Although such systems can have a role in medical office and hospital automation, such systems are often limited to a research location, e.g., using a knowledge base which correlates patient symptoms to diagnosis of an illness and/or recommendations of a treatment, for only selective uses. In other words, the physician or other medical personnel remain the primary patient contact and interface, and diagnosis and treatment decisions usually remain substantially in the hands of the physician.
Because the physician or other medical personnel, e.g., nurses, nurse assistants, technicians, remain the primary patient contact and primary decision maker, the physician or other medical personnel are also primarily responsible for creating the medical record or history of a patient such as the creating or forming of a progress note or narrative description during a patient encounter. These medical records often become more and more critical to an office, hospital, or other organization, e.g., the medical records representing a complete record of a patient""s health care administered by a physician, other medical personnel, or the facility in general. Accordingly, attempts have been made over the years to automate the medical history taking process. Examples of such attempts can be seen in U.S. Pat. No. 4,130,881 by Haessler et al. titled xe2x80x9cSystem And Technique For Automated Medical History Taking,xe2x80x9d U.S. Pat. No. 5,146,439 by Jachmann et al. titled xe2x80x9cRecords Management System Having Dictation/Transcription Capability,xe2x80x9d U.S. Pat. No. 5,265,075 by Bergeron et al. titled xe2x80x9cVoice Processing System With Editable Voice Files,xe2x80x9d and U.S. Pat. No. 5,327,341 by Whalen titled xe2x80x9cComputerized File Maintenance System For Managing Medical Records Including Narrative Reports.xe2x80x9d
Some of these automated medical record forming systems, for example, require that a user enter information about a patient into selected fields so that the medical record is formed by question and answer prompts or data entry into what is essentially a form, e.g., based upon a limited set of predetermined answers to a prompted question. Others of these systems merely allow transcribed files to be accessed again or allow portions of files which are similar to not need repetition. Such systems, however, provide little utility for a physician directly and require that the physician adapt to some style, format, language usage, or other constraints of the automated system and provide little or no freedom for the physician""s own style. Additionally, such systems often require additional personnel to transcribe, enter and manage the forms and require personnel training and learning of the particular format used by the system. Others of these automated medical record forming and management systems often record and transcribe dictation for entry into a computer or data base which then can create, update, and manage medical records. Some of these systems allow a physician to dictate but require a transcriber to extract pertinent sections from the dictated report for entry into the computer in predefined categories. Accordingly, these systems also require additional personnel to transcribe dictation, enter and manage the forms, and to be trained and learn the particular format used by the system.
In view of the foregoing, the present invention advantageously provides an apparatus and method for forming a medical record which does not require a separate transcriptionist for transcribing a dictated medical record. The present invention also advantageously provides an apparatus and method for forming a medical record which allows a physician or other medical personnel to freely dictate medical data related to a medical record so that the resulting product will be a medical record in either a selected or predetermined format. The present invention additionally advantageously provides an apparatus and method for forming a medical record which recognizes free, unprompted, and unstructured speech from a physician or other medical personnel and responsively translates the speech into a structured medical record format which is either selected by the user or predetermined by the user or system. The present invention also additionally provides an apparatus and method for forming a medical record which recognizes key medical words or terms in the free, unprompted, and unstructured dictation so that relationships can be made between the medical terms, other related medical terms, a patient""s conditions, and potential treatments to thereby form at least a draft medical record therefrom. The present invention further advantageously provides a medical record which is structured or formed from a relationship between medical terms used by a physician or other medical personnel and other related medical terms, patient conditions, and potential treatments. The present invention still further advantageously provides a medical record which is formed by free, unprompted, and unstructured dictation by a physician or other medical personnel by recognizing key medical words or terms in the dictation to thereby form a medical record based upon either a selected or predetermined format.
More particularly, a medical record forming and storing apparatus is provided which preferably includes voice inputting means, e.g., preferably provided by a voice recorder, for inputting the unprompted and unstructured free dictation of at least one medical personnel such as a physician, voice processing means, e.g., preferably provided by a voice processor, responsive to the voice inputting means for processing the recorded voice from the voice inputting means and generating voice data therefrom, and key term recognizing means, e.g., preferably provided by a key term recognizer, responsive to the voice processing means for recognizing key medical terms freely dictated by the at least one medical personnel. The apparatus also preferably includes medical term matching means, e.g., preferably provided by a medical term matcher, responsive to the key term recognizing means for matching medical terms used by the at least one medical personnel at least with patient conditions and/or treatments. The medical term matching means preferably includes a knowledge database relating patient conditions with patient treatments of the conditions so that the knowledge base assists in further describing at least the actual condition and/or treatment of the patient by adding additional data, e.g., a more complete description, to a medical form which is or will be created. The apparatus can further include medical record creating means, e.g., preferably provided by a medical record creator, responsive to the medical term matching means for creating an actual patient medical record therefrom.
As used herein, the term free dictation means the unstructured and unprompted dictation of the at least one medical personnel, e.g., a physician. By unstructured and unprompted, it is recognized that words, sentences, and paragraphs have structure which often prompts additional structure such as a limited set of predetermined answers to a prompted question. Nevertheless, this is not the intent of the meaning of unstructured and unprompted. Rather, medical personnel such as physicians are allowed to freely dictate words, terms, sentences, phrases, paragraphs, and other language structure without the necessity of using only selected words, terms, phrases, paragraphs, and other structure required by the system into which the physician or other medical personnel dictates or speaks. In other words, the dictation does not have to be within a given format required by the medical record forming system outside of normal language usage by the speaking or speech of the medical personnel and is preferably not based upon a limited set of predetermined answers to a prompted question.
By advantageously using or keying off of key medical terms used by a physician or other medical personnel such as in free, unprompted, and unstructured dictation, the apparatus and method provide freedom for the physician to talk, speak, and dictate according to the physician""s personal preferences, style, language, vocabulary, tone, and other desires when forming a medical record. Non-key medical terms or other unrecognized words, for example, can advantageously be discarded or stored for future reference. The physician, for example, does not have to fit within the constraints or format requirements of the system which receives the dictation and forms the medical record therefrom. Because the free dictation is the preferred format and key medical terms are recognized by the apparatus, additional personnel to transcribe the physician""s dictation are not needed.
According to one aspect of the present invention, the key term recognizing means, for example, can include key medical term storing means for storing a plurality of key medical terms, comparing means responsive to the key medical term storing means for comparing the voice data with key medical terms within the key medical term storing means, and separating means responsive to the comparing means for separating the key medical terms from the non-key medical terms.
According to another aspect of the present invention, the medical record creating means, for example, can advantageously include draft record generating means for generating a draft medical record related to the at least one medical personnel""s dictation for review by the at least one medical personnel, record revising means responsive to the at least one medical personnel for revising the draft medical record, and record accepting means responsive to the at least one medical personnel for accepting the draft medical record.
According to still further aspects of the present invention a medical recording forming and storing apparatus preferably includes a voice input device for inputting dictation of at least one medical personnel, a voice processor responsive to the voice input device for processing the inputted voice and generating voice data therefrom, a key term recognizer responsive to the voice processor for recognizing key medical terms dictated by the at least one medical personnel. The key term recognizer preferably includes a key medical term database for storing a plurality of key medical terms therein. The apparatus also preferably includes a medical term matcher responsive to the key word recognizer for matching recognized key medical terms used by the at least one medical personnel with patient conditions and/or treatments to thereby add additional data thereto.
The present invention also advantageously provides a medical record having a selected format. The medical record preferably includes a plurality of primary key medical terms responsively generated by the voice of at least one medical personnel and arranged in the selected format. The primary key medical terms are preferably generated by the free, unprompted, and unstructured dictation of the at least one medical personnel and preferably include at least patient conditions and treatments. The medical record also includes additional secondary text responsively generated by the presence of the primary key medical terms and arranged in the selected format. The additional secondary text preferably at least includes medical terms describing patient conditions and/or treatments related to the plurality of primary key medical terms describing patient conditions and/or treatments but not being a subset of the plurality of primary key medical terms.
The present invention yet further provides methods of forming a medical record. A method of forming medical records preferably includes generating a plurality of key medical terms, recognizing the plurality of key medical terms responsive to a key medical term database having a plurality of key medical terms stored therein, matching recognized key medical terms used by the at least one medical personnel with known patient conditions and treatments stored in a knowledge database which relates patient conditions with patient treatments of the conditions so that the knowledge base assists in further describing at least the actual condition and/or treatment of the patient by adding additional data thereto, and creating an actual patient medical record responsive to the matched recognized key medical terms.
Another method of forming medical records according to the present invention preferably includes inputting unprompted and unstructured free dictation of at least one medical personnel, processing the inputted voice to thereby generate voice data therefrom, recognizing key medical terms freely dictated by the at least one medical personnel responsive to a key medical term database having a plurality of key medical terms stored therein, matching recognized key medical terms used by the at least one medical personnel with known patient conditions and/or treatments to thereby add additional data thereto, and creating an actual patient medical record therefrom.
Yet another method of forming medical records according to the present invention preferably includes inputting dictation of at least one medical personnel, processing the recorded voice to thereby generate voice data therefrom, recognizing key medical terms dictated by the at least one medical personnel responsive to a key medical term database having a plurality of key medical terms stored therein, and matching recognized key medical terms used by the at least one medical personnel with known patient conditions and/or treatments to thereby add additional data thereto.
By providing a knowledge database, or other knowledge storage medium which at least includes patient conditions and/or also preferably patient treatments or potential treatments related to a corresponding patient condition, the present invention advantageously provides an apparatus and method of forming a medical record which adds additional text which are also preferably related to the same patient conditions and/or treatments to the existing medical terms to provide a more complete record or a record according to either a selected or predetermined format to thereby further describe additional data or information desired to be in a medical record. This feature, for example, can advantageously allow a physician or other medical personnel to dictate as desired and yet have some assurance that the first draft of the medical record will be fairly complete. The physician, for example, can then revise the medical record. By reference to the same knowledge database for checking on the impact of the revised or additional terms provided by the physician with the terms added from the knowledge database, the apparatus can then provide a revised medical record. Such revisions advantageously can be repeated until the medical record is acceptable to the physician.